The Use of Ambulatory Strategies for the Diagnosis and Treatment of Obstructive Sleep Apnea in Adults

Eusebi Chiner; Ada L Andreu; Jose N Sancho-Chust; Alicia Sánchez-de-la-Torre; Ferran Barbé


Expert Rev Resp Med. 2013;7(3):259-273. 

In This Article

Treatment Compliance Programs

To the best of our knowledge, compliance to general recommendations in OSA has not been evaluated. As explained above, electronic monitors could lead to evaluation of ambulatory programs, improving OA compliance in the future. Surgical intervention does not need a patient's compliance, so it cannot be evaluated. Only programs to improve CPAP compliance have been evaluated in OSA patients and the present review will focus on this modality of treatment.

Several studies have tested strategies that serve as complements to the usual follow-up, such as back-up by phone, educational group sessions and intensive home nursing support. Many such resources can be found in the literature. They can be divided into three categories (Box 2)[74–76] and range from very simple measures to extremely complex interventions that are sometimes unfeasible in the day-to-day life of a hospital. Here follows a review of some aspects of the most relevant studies.

Simple Interventions

Most programs combine several strategies, which may help improve compliance but also makes it more difficult to make comparisons. It seems to be the case, however, that some kind of intervention is better than none.

For example, Chervin et al. divided 33 patients into three groups: one with usual practice, another with a weekly telephone call to reinforce the use of CPAP and a third with written documentation about the disease and its treatment. At 8 weeks, the group receiving written documentation used CPAP for 2.7 h more than the nonintervention group, while the telephone contact group used CPAP for a further 1.3 h. Although the differences were not statistically significant (p = 0.059), probably due to the small sample size, this study reinforces the idea that simple interventions improve compliance.[77]

Aloia et al. have also evaluated a simple intervention consisting of educational talks. They divided 12 patients into a control group and an intervention group that received a 45-min session before starting treatment, and another a week later. The first described the consequences of OSA and the effectiveness of CPAP, while the second discussed the changes that had been observed, such as improvements in health (hypertension, heart problems), side effects and so on as well as reviewing the initial objectives and proposing realistic, individualized targets. All patients underwent a monitoring test at the beginning and end of the study, and compliance was recorded by a microprocessor built into the CPAP that gave a reading at 1, 4 and 12 weeks. In the first reading, no differences were observed between the groups, but at 12 weeks, the intervention group used CPAP for 3.2 h more, and also had greater improvement in an alertness test than the control group.[78]

In 2007, Richards et al. studied 100 patients divided into an intervention group that received two 1-h sessions of cognitive behavior therapy with educational videos, a customized interface and verbal and written information about the disease and its treatment, as well as instructions for relaxation techniques that could be followed with their partners. The control group received only the usual treatment. At 28 days, the treatment group presented a greater adherence with a difference of use of 2.9 h (p < 0.001). Only four patients in the intervention group decided not to initiate treatment compared with 15 who rejected the therapy in control. The study thus concluded that this type of education favors acceptance of and adherence to the treatment.[79]

There have been other experiences within the field of psychology, such as the study by Olsen et al. in which a group of patients was randomized to receive three sessions with a nurse who conducted a motivational interview to improve adherence. They were compared with a control group with good results, especially in the third month (4.63 h against 3.16 h; p = 0.005). The authors therefore concluded that the greatest benefits can be achieved by adding psychological support to the monitoring strategies used.[80]

Other authors have used different techniques, such as music therapy. This was the case with Smith et al., who divided their OSA patients into two groups, each provided with a cassette to listen to. The intervention group received a cassette entitled 'Get into the habit of using CPAP every day', which included relaxing background music, breathing exercises and a guide to the optimal placement of the device to enhance sleep. This was accompanied by written information and a request to keep a diary. The control group received a different cassette, entitled 'Get in the habit of taking vitamins in your diet'. After comparing both, the authors found better adherence in the first group, but only during the first month.[81]

Sometimes compliance has been linked to the number of patients who attend a consultation after prescription of the treatment. It seems that those patients who return to the hospital are more motivated, irrespective of whether or not they are good compliers, and if the staff have the opportunity to attend to them, they can identify problems and encourage the use of the therapy. Along these lines, Lewis et al. divided patients into a control group and an intervention group provided with a telephone number to call in the event of a problem and a video on OSA. This group also received a call from a technician in the first week, involving a structured interview to identify problems and offer advice, and visited a doctor a week after starting the treatment. The remaining visits were the same for both groups. The authors observed from the start that the number of patients who came to the consultations was higher in the intervention group (100% in the intervention group vs 89% in the control group per month; p = 0.04), although the statistical significance disappeared in subsequent visits (83 vs 69% per year; p = 0.17).[82] In a similar study, Jean Wiese et al. showed their intervention group an educational video with two characters talking about the disease. At 4 weeks, 73% of the patients in this group came back for a consultation compared with 49% in a group with no intervention (p = 0.0174). There were no differences with regards to the hours of use, although this could be attributed to the fact that many patients failed to bring CPAP data to the consultation. The data captured from the device's internal clock was therefore incomplete, making it impossible to draw any conclusions.[83] Nevertheless, both studies concluded that extra support increases the number of patients who come to consultations and this is the first step toward solving problems early or considering alternative treatments.

Complex Interventions

Other authors have implemented more complex programs that combine educational activities with calls and visits, either to the hospital or to the home, attended by a sleep specialist or nursing staff. Hoy et al. studied 80 consecutive patients randomized into two groups. The basic support group was shown educational videos with the staff of the sleep laboratory in attendance to make the appropriate adjustments to the interface. After the prescription of CPAP titration, a nurse phoned from the hospital at days 2 and 21 to evaluate and solve problems. The patients were then evaluated in the hospital by a doctor and a nurse at 1, 3 and 6 months. The intensive support group received not only the basic support but also home educational visits for three consecutive nights. After starting treatment, the patients received personal visits at home from nurses at 7, 14 and 28 days and the fourth month. Differences were found in patients with intensive support with increased use of CPAP at 6 months (5.4 h vs 3.9 h/night; p = 0.003), leading to the conclusion that an intensive program supervised by nursing staff improves compliance.[76]

Another similar study included basic support plus education on the use of CPAP provided by a nurse in a clinic, adaptation to the device involving fitting the appropriate mask and titration performed in the hospital. The patients were monitored by a doctor and a nurse in the clinic at 1 month and 3 months. The intensive support group, meanwhile, received extra education in OSA and CPAP from a video made by a doctor, an additional educational session conducted by a nurse, a consultation with a doctor after 1 and 2 weeks and telephone contact with a nurse on days 1 and 2 and at 1, 2, 3, 4, 8 and 12 weeks. In this case, the authors did not find any differences in compliance at any point, although there was a striking improvement in the intervention group in the score of the Calgary Sleep Apnea Quality of Life Index. These results were attributed to the variety of measures featured in the basic support, in all probability far beyond routine practice.[84]

Meurice et al. analyzed four different types of approach, namely two types of educational strategies, one basic and one complex, and two types of monitoring. The educational strategies include SP (standard education from the prescriber), which includes oral information, literature on the disease and therapy and a demonstration of the use of CPAP, while RP (education reinforced by the prescriber) includes all the above plus more elaborate written material about CPAP and a special emphasis on compliance and use. As for the monitoring, there is SH (standard educational homecare), in which a technician goes to a patient's home and begins the treatment while explaining its use to the patient; the other type is RH (education reinforced by the homecare team), in which not only is the therapy started under supervision at home but educational control visits are also made after 1 week and 1, 2 and 3 months. Meurice et al. combined each educational strategy with each type of monitoring to obtain four groups for the analysis (SP + SH, SP + RH, RP + SH, RP + RH). All the patients were followed up for 3 months and from then on, they were evaluated every 3 months following a clinical routine until a follow-up of 1 year was completed. No significant differences were found in compliance in any of the follow-up points.[85]

Another important study was performed by Damjanovic et al. in 2009. These authors sought to find differences not only according to the strategy used but also the device with which the patient was treated. They analyzed 100 individuals diagnosed with OSA and randomized them into four groups: standard or intensive support and treatment with CPAP or auto-CPAP. Standard support consisted of a regular visit to the clinic at 3 and 9 months after diagnosis. In intensive support, this was complemented by home visits by trained sleep laboratory technicians 1, 2, 4, 5 and 6 months after the start of treatment. After 9 months, the intensive support group showed a significantly higher number of hours of use (5.7 ± 0.2 vs 4.6 ± 0.4) and days of CPAP use than the standard support group. Again, it seems that intensive back-up in the first weeks of treatment has a bearing on the subsequent use of CPAP. However, these authors did not find any differences in compliance with respect to the use of CPAP or auto-CPAP.[86]

In conclusion, it seems that the first few weeks are crucial to further adherence and these studies reinforce the idea that any extra support at this stage will have a positive impact on compliance. Even so, it is necessary to find programs that are sufficiently simple and inexpensive to be put into practice in the majority of centers.